1. Endocrine Emergencies

2. Name a Few… DKA HONK (HHOS) Addisonian crisis Thyroid storm
Myxoedemic coma

3. What’s the Diagnosis?
83yr woman with 3/7 histroy of malaise and polyuria. PMH type I DM and HTN
HR 100, BP 100/60, GCS 14, SaO2 100% on high flow O2
Na 125
K 6.0
Cl 81
HCO3 7
Ur 25
Cr 262
Glu 54.5
Osmolality 337

4. DKA Definition Mortality 5-15% (less in children)
BSL increased
Ketones present
Anion gap >10
HCO <15
pH <7.3
Mortality 5-15% (less in children)
Beware if pregnant: 30-50% mortality

5. All About Ketones Beta-hydroxybutyrate Acetoacetate Acetone
Detected by Medisense blood test
Higher in alcoholic ketoacidosis than in DKA
Acetoacetate
>6x the levels of above AFTER conversion (ie. May initially be negative)
measured by Ketostix urine test
Acetone
Detected on Acetest
Responsible for ketotic breath
How do ketones impact on management?
Endpoint = ketones cleared, normal anion gap

6. Other Vital Stuff
VBG Anion gap metabolic acidosis
Maybe metabolic alkalosis (vomiting), resp alkalosis (hyperventilation)
BSL How does BSL impact on management?
Aim decr no more than 5/hr
Na… How do I calculate corrected Na???? Average deficit 5-10mmol/kg
Na + ( (Glu – 5.5) / 3 ) So if Na is 128 and Glu is 65 – what is real Na?
How does Na impact on management?
K… How do I correct K for pH???? Average deficit 3-5mmol/kg
Decr pH by 0.1 = Incr K by So if pH is 7 and K is 5.7 – what is real K?
How does K impact on management?
Osmolality… How do I calculate osmolality? Average body H20 deficit 100ml/kg
Do I even have to? Can’t I just measure it?? (ie. 10% dehydration)
(2 x Na) + Glucose + Urea
How does osmolality impact on management?
Aim decr by no more than 1-2/hr
Any other investigations?
?precipitant; ?ARF; ?level of long-term control

7. Let’s look at that gas again…
Na 125
K 6.0
Cl 81
HCO3 7
Ur 25
Cr 262
Glu 54.5
Osmolality 337

8. Management of DKA It’s bloody confusing and hard to remember
Split into…
1) IV fluids
2) Potassium
3) Insulin
4) NaHCO3

9. Fluids Adult Child 1L stat 10-20ml/kg bolus
 rpt until haemodynamically stable
1L over 1hr Replace deficit over 48hrs
 1L over 2hrs
 1L over 4hrs Deficit = %dehydration x weight x 10
 1L over 10hrs
Use N saline
Use 0.45% saline Use 0.45% saline and correct over 72hrs
if Na >150 / Osm > if Na >150 / Osm >320
Watch: Na, osmolality, BSL
Change to 0.45% saline + 5% dex when BSL <15
and also if…..
BSL decreasing too fast (ie. >5/hr)
BSL <10 but ketones ongoing

10. Potassium How do you correct for pH again?
Only add K in 2nd hour / once UO / K <5
Adult
K = 10mmol/hr
K = 30mmol/hr
K <3 = 40mmol/hr
Child
Add 40mmol to 1L bag

11. Insulin Start after 1hr of fluids if K >3.4 (otherwise
replace K first)
Do you give a stat dose of actrapid?
Actrapid infusion
0.1iu/kg/hr (max 6iu/hr)
Decrease to 0.05iu/kg hr if….
BSL <12 (stop for 15mins if still too low despite this)
Aim for BSL decrease of no more than 5/hr
K <3

12. NaHCO3 What are the indications? What is the dose?
pH <7
HCO3 <5
Life threatening hyperkalaemia
Coma
Haemodynamic compromise
unresponsive to IV fluids
What is the dose?
0.5 – 2mmol/kg over 1-2hrs
What is the endpoint?
pH >7.1
HCO3 >10
What are the risks?
Worsened intracellular acidosis, hypokalaemia, hypernatraemia, osmolar shifts and cerebral oedema, volume overload

13. Cerebral oedema
70% mortality; 10% have ongoing neuro deficit; more common in children
Onset 4-12hrs after starting trt
What are the symptoms?
Headache, decr LOC, decr HR, incr BP, pupil changes, seizure, urinary incontinence
How do you treat it?
Mannitol 0.5-1g/kg
3% saline 5-10ml/kg over 30mins
Half maintenance fluids

14. Hyperglycaemic Hyperosmolar State
DKA
HHOS
Mortality up to 15%
Mortality up to 45%
BSL +
BSL ++++
pH <7.3
pH >7.3
Anion gap >12
Anion gap <12
HCO3 <15
HCO3 >15
Ketones ++++
Ketones -/+
Maybe incr osmolality
Osmolality >
H20 deficit 100ml/kg (10% dehydration)
H20 deficit more (20-25% dehydration)
Higher Na + K deficit
Resus with N saline
Use N saline thereafter unless Na >150 / Osm >320
Use 0.45% saline thereafter (unless low corrected Na)
Change to 0.45% saline + 5% dex when BSL <15
Replace deficit over 48hrs
Replace deficit over 48-72hrs
Similar K replacement
Actrapid 0.1iu/kg/hr (max 6iu/hr)
Actrapid 0.05iu/kg/hr (max 3iu/hr)
Heparin important (hypercoag state)

15. What’s the diagnosis (bearing in mind this is an endocrine talk)?
An 85 year old man is brought to your Emergency Department fitting. His family say that he has been lethargic and weak for the last two weeks. He has a PMH of polymyalgia rheumatica. These are his initial biochemistry results.
Na 99 mmol/L
K 5.9 mmol/L
Cl 68 mmol/L
BSL 2.2mmol/L
HCO mmol/L
Urea 10.1 mmol/L
Cr 180 umol/L
pH 7.1
Anion gap normal
pCO2 31 mmHg
pO mmHg
BE 2.4
HCO mmol/L

16. Addisonian Crisis Back to Part One’s!! Effects of cortisol
Incr BSL (gluconeogenesis, lipolysis, decr ketogenesis, decr insulin release)
Effects of aldosterone
Incr Na (incr reabsorption)
Decr K (incr excretion in DCT)
Alkalosis (incr H excretion)
So…. what changes may be seen on bloods in view of the above?
Dehydration – fluid resistant hypotension
Decr osmolality
Decr BSL
Decr Na, Cl
Incr K
Non-anion gap metabolic acidosis
If 2Y hypoadrenalism patient euvolaemic with lower K, as aldosterone is still working

17. Recognising Addisonian Crisis
Who gets it? 1Y
Long-term steroids stopped abruptly
Adrenal haemorrhage (neonates, anticoagulated folk, sepsis (name the syndrome), trauma)
Addison’s disease
Prior surgical removal
Adrenal destruction due to other cause: infection (eg. TB, HIV, CMV), thrombosis, metastatic Ca 2Y
Head trauma
Meningitis
In pregnancy (name the syndrome).
Pituiary failure
How do they present?
Hypotension, lethargy, weight loss,
weakness, N+V, abdo pain, diarrhoea
Ie. Non-specifically unwell and not responding
to conventional treatment plus characteristic
electrolyte changes
Freidrick – waterhouse
Sheehan syndrome

18. Management Investigation Management Name the investigation
IV fluids ++++ (vasopressors may be needed)
Dextrose
Treat K if needed
Dexamethasone 10mg IV stat (give initially as doesn’t interfere with investigations)
…then hydrocortisone 250mg IV stat
ACTH stimulation test, synacthen then look at cortisol = 1Y will not have cortisol rise, 2Y will
ACTH
Free cortisol levels

19. What’s the diagnosis?
17yr old female presents feeling anxious, unwell, tremulous, hyperventilating, looking flushed. Recent history of abdominal pain and diarrhoea.
HR 130, T 38, BP 140/87, RR 24
On examination: gallop rhythm, bibasal crepitations, abdomen SNT
pH 7.8
PCO2 15 mmHg
PO2 192 mmHg (75-100)

20. Thyroid Calamities Back to Part One’s again! Effect of T3+4
Incr metabolism
Incr GI motility
Incr glucose absorption
Incr sensitivity to epinephrine and norepinephrine, increased beta-receptors

21. Thyroid Storm Clinical diagnosis – labs don’t differentiate
Mortality 10% treated, 90% untreated with death due to CV collapse
Who gets it?
Undiagnosed Graves
Meds – XS thyroxine / withdrawal from anti-thyroid drugs / iodine or contrast
Stressor – MI, DKA, OT

22. Recognising Thyroid Storm
Diagnostic criteria
Fever >37.8
Incr HR out of proportion to fever (ie. >120)
CNS disturbance (eg. Altered LOC, seizures)
Other
AP, N+V, diarrhoea, high output CCF (wide pulse pressure, S3 gallop rhythm), HTN, dehydration, sweating
Investigations – non-specific

23. Management A + B C Treat cause Definitive treatment Supportive care
Give O2 as consumption increased C
IV fluids containing dextrose
Cardioversion better than drugs for arrhythmias
Treat cause
Definitive treatment
Esmolol mcg/kg bolus  infusion (safe as short half life; titratable; blocks cardiac and peripheral effects and slows conversion of T3 to T4)
If less severe can use PO propanolol
Hydrocortisone 100mg IV (slows conversion of T3 to T4 and decreases hormone release)
Propylthiouracil / methimazole / iodide
Supportive care
Ongoing fluids, monitor electrolytes and BSL, treat fever

24. What’s the Diagnosis? (This was an actual patient I saw last week)
58yr old man with non-specific malaise
PMH: hyperthyroidism treated with radioactive iodine; known to be non-compliant with treatment
OE: normal observations; mild oedema around eyes; examination otherwise unremarkable

25. Myxoedema Coma Who’s ever seen one???
Mortality 50%; same triggers as thryoid storm
Symptoms
A: hoarseness, glottic oedema
B: decr RR
C: decr BP, CCF
D: decr LOC, hypothermia without shivering, seizures
E: hypoglycaemia, paralytic ileus
Management
ABC, treat cause
T3 has rapid effect, T4 has smoother improvement, give hydrocortisone
Monitor electrolytes esp Na and titrate fluids accordingly
Rewarming

26. Anything else you want to talk about…?
Hyponatraemia?
Hypernatraemia?
Metabolic acidosis?
Sodium bicarb use?